• Rickets: refers to deficient mineralization and architectural disruption of the growth plates
of bones
• Osteomalacia: impaired mineralization of the bone matrix.
– Rickets and osteomalacia usually occur together when growth plates are open (children); only
osteomalacia occurs after growth plates have fused (adults)

• Mineralization defects are classified according to the predominant mineral deficiency.
– Calcipenic rickets is caused by calcium deficiency, which usually is due to insufficient intake or
metabolism of vitamin D, and in some cases insufficient intake or absorption of calcium in the setting
of normal vitamin D levels.
– Phosphopenic rickets is usually caused by renal phosphate wasting.

Figure
Figure 1. Common bone abnormalities
in childhood rickets

2.

Radiological findings in
childhood rickets. Note the cupping of the
metacarpals, osteopenia and enlarged
metaphyses leading to widening of the
wrist. Source: radiopaedia.org

RATIONALE
• In March 2013, the MSF team in Khamier began screening for clinical rickets among
children under 5 years of age presenting to the Emergency Department.
• A clinical management program was put in place.

 The suspected cases described here are based on clinical criteria. Laboratory data
(vitamin D levels) and radiographic reports have not yet been analyzed. When this data is
added to the database, it is possible that some suspected cases may be reclassified.
 Suspected rickets cases are evenly distributed among boys and girls.
 Most cases (69.6%) come from Khamier district.
 The prevalence of malnutrition among suspected rickets cases is high (GAM= 60.2% and
SAM=28.6%).
 The most common findings on physical exam were skull bossing (83.7%), open
fontanelles (80.2%) and rachitic rosary (64.3%).
 Only 1.4% of cases were reported to have been born prematurely.
 Follow up data were not available at the time of analysis but will be added to the
databases. This information will allow for a better understanding of clinical progression
over time.

HORIZONS
 Follow-up data and radiographic reports will be added to the database.
 Spatial analysis of cases would allow targeting further study and intervention areas.
 Investigate the link between rickets and malnutrition in this population for evidence of
causality.
 Once the database is completed, the current clinical and lab diagnosis algorithms can be
evaluated.

INTRODUCTION
With the intention of simplifying the monitoring of programs treating multidrug resistant tuberculosis (MDR TB) patients, the World Health Organization (WHO) revised the
definition of treatment failure in 2013.

WHO 2008 definition of failure for MDR TB

WHO 2013 definition of failure for MDR TB

Treatment will be considered to have failed if
• Two or more of the five cultures recorded in the final 12 months of therapy are
positive, or
• If any one of the final three cultures is positive, and/or
• If a clinical decision has been made to terminate treatment early because of poor
clinical or radiological response or adverse events. These latter failures can be indicated
separately in order to do sub analysis

Treatment terminated or need for permanent treatment change of at least 2 classes
of anti TB drugs because of one or more of the following
• Lack of culture negativation by 6 months for MDR TB (3 month for PDR TB), and/or
• Resistance amplification, and/or
• Bacteriological reversion (at least two positive smears or cultures at least 30 days
apart) after conversion to negative, and/or
• If a clinical decision has been made to terminate treatment early due to poor
response or adverse events. These latter failures can be indicated separately in order
to do sub analysis.

Treatment outcomes reporting for MDR TB
If a case is assigned an outcome of Treatment failure and the patient is restarted on a revised regimen within the same year then, the case is not assigned another outcome. In
other words, only the first outcome met is recorded for outcome monitoring.

METHODS
• Retrospective analysis on routinely collected data in 5 Médecins Sans Frontières DRTB programs in Armenia, Abkhazia, Kenya, Swaziland and Uzbekistan.
• MDR TB confirmed patients were enrolled between 2001 and 2009 and treatment regimens were based on 2008 WHO recommendations.
• As the treatment was individualized and no maximum duration for the intensive phase was defined, we chose a 6 month cut off for culture negativation.
• We report the proportion of patient meeting the new definition of treatment failure.
• Treatment failures using the 2013 revised definition were presented compared to the patients’ outcomes using 2008 WHO outcome definitions.

OBJECTIVE
• To assess the proportion of MDR TB treatment failures using the revised WHO 2013 definition

DISCUSSION
• The new definition of treatment failure will have a significant impact on the reporting of MDR TB treatment outcomes.
• It may dramatically increase the proportion of failures and decrease the proportion of defaulters, probably better reflecting the reality of the treatment effectiveness.
• With the new definitions, patients failing treatment will be registered under a new MDR TB regimen and will have another treatment outcome, however this final outcome will
not be used for programme monitoring, only the first outcome met is recorded for outcome monitoring.
Correspondence: Mathieu Bastard, Epicentre, 8 rue Saint Sabin, 75011 Paris; email: mathieu.bastard@geneva.msf.org

INTRODUCTION
• Access to antiretroviral treatment (ART) has greatly increased in resource limited settings in the past decade.
• Most research related to HIV programs and patients have focused on the evaluation of treatment outcomes after the start of therapy. Nevertheless, improvement of
the quality and effectiveness of HIV care requires monitoring and evaluation of patient outcomes before and after the start of ART.
• Gaining understanding of pre ART is needed to improve strategies of care and maximize long term patient outcomes.
• In Médecins Sans Frontières (MSF) supported HIV programs, 20 to 35% of the patients who are currently receiving HIV care have not yet started ART.
• This study describes patients’ characteristics, initial and acquired eligibility, and delays in starting ART. It reports also rates of mortality and lost to follow up (LTFU) and
associated risk factors during the pre ART period.

HIV positive patients aged 15 years old in 48 HIV programs.
ART naive
Inclusion between January 1st 2005 and December 31st 2011.
1 year between inclusion and administrative censoring date.

Pre ART follow up in the HIV programs:
• Follow up visits every 3 or 6 months .
• CD4 count testing every 6 months but no viral load testing.

Descriptive statistics:

Survival analysis:

• Access to HIV care: time between HIV testing and program
inclusion.
• Pre ART follow up visits: frequency and time between visits.
• ART eligibility at enrolment and delay in ART start.
• Interruptions in follow up: not attending a visit for at least 60
days after appointment date.
• Acquired eligibility during pre ART follow up and delay in ART
start.

DISCUSSION
•This study shows an important proportion of patients eligible at enrolment reflecting that most patients presented with advanced stage of HIV disease highlighting the need to
increase access to HIV program at an earlier stage of the disease.
• Pre ART mortality remains higher among patients with advanced stage of disease , low BMI and among men (similar to known risk factors of on ART mortality).
• Pre ART LFU was high, especially during the first months after inclusion, stressing the need to also improve pre ART care to maximize program retention, particularly among
patients with high level of CD4 counts at enrollment, men and younger patients.
• Better understanding of both, the barriers in accessing, and the factors facilitating long term retention in HIV care among men would be important to design appropriate innovative
interventions specifically designed for this high risk group. Strategies of decentralization of HIV testing and care services to the work place might be effective in some contexts.
Correspondence: Mathieu Bastard, Epicentre, 8 rue Saint Sabin, 75011 Paris; email: mathieu.bastard@geneva.msf.org

32515 adolescents and young
adults in the study HIV
programs
3937 (12.1%) with only 1 medical visit
28578 (87.9%) included in analysis
15059 (52.7%) started on
ART

13519 (47.3%) never started
on ART

We would like to thank the ministries of health of the countries and the MSF field teams for their daily work and effort to provide care to the patients and for data collection; the other members of
the Epicentre FUCHIA team working in Paris (Elisabeth Poulet, Serge Balandine, Sarala Nicholas and Loretxu Pinoges) and in Africa (Laurence Ahoua and Megan McGuire) for their support in
data collection and data quality maintenance.

4272 children initiated ART between Dec 2001 and Dec 2011

238 starting ART <1 year before closing
database. 85 with only one recorded visit

3949 children included

We would like to thank the ministries of health of the countries and the MSF field teams for their daily work and effort to provide care to the patients and for data collection; the other members of
the Epicentre FUCHIA team working in Paris (Serge Balandine, Sarala Nicholas and Loretxu Pinoges) and in Africa (Laurence Ahoua and Megan McGuire) for their support in data collection
and data quality maintenance.

• Community-based management of acute malnutrition (CMAM) is recommended as
the standard of treatment for severe acute malnutrition (SAM) since 2007.

• During the total period, 50,841 children were admitted in the TFP:
children during period A - 26,049 children during period B

• Simple diagnostic tools for SAM are needed for recruitment within the community,
particularly where human resources are difficult to supervise.

• Median age was 13 months [IQR: 10-20] and sex ratio M:F was 0.9 at admission.

• Compared to WHZ, Mid Upper Arm Circumference (MUAC) is :
– simple, rapid, less prone to errors,
– facilitates coverage of therapeutic feeding programs (TFP),
– identifies younger children at higher risk of mortality.
• MUAC can be used:
in community-based nutritional programs
in emergencies, when close supervision is often not possible.
• The World Health Organization (WHO) endorsed MUAC as an independent
admission criterion to TFP for children 6-59 months old with acute malnutrition since
2008.
• As of 2009, WHO recommends 15% weight gain to define nutritional recovery and
discharge from program due to lack of evidence.

Period

MSF in Burkina Faso, Titao -Yako
• Médecins Sans Frontières (MSF) and the Ministry of Health implemented a CMAM
program using MUAC for both, screening and admission criterion to TFP in Burkina
Faso.
• Stunting and wasting prevalence are high in Titao and Yako, in North Region of
Burkina Faso (see map).
• Malnourished children were admitted if MUAC <120mm
• From Sept 2007 to Mar 2009, percent weight gain, relative to admission weight,
determined recovery
• From Apr 2009 to Dec 2011, absolute value of MUAC, with a minimum stay of 4
weeks, was used as discharge criterion

Program outcomes and treatment response
• 90.4% of all admissions recovered: 22,094 (89.1%) during period A and 23,865 (91.6%) during
period B (Table 2).
Table 2: Outcomes of children admitted to TFP, MSF program Titao-Yako, Sept 2007 – Dec 2011

Period
Cured

Outcomes
Non
responders
n(%)
384 (1.5)

Defaulters
n(%)

Referred
n(%)

n(%)

Death
n(%)

Period A

22,094 (89.1)

260 (1.0)

1961 (7.9)

93 (0.4)

Period B

23,865 (91.6)

279 (1.1)

515 (2.0)

1248 (4.8)

140 (0.5)

Total
period

45959 (90.4)

539 (1.1)

899 (1.8)

3209 (6.3)

233 (0.4)

• Average length of stay [ALS] in the program for children recovered during period A was 53.9
days compared to 37.0 days for those recovered over period B.
- During period A, ALS was shorter for the most malnourished
-During period B, ALS was longer for the most malnourished (Figure 1).

Anthropometry status of upon discharge by MUAC categories at admission
• During period A, mean MUAC and WHZ at discharge were respectively < 120 mm and < -2
zscore among recovered children whose MUAC upon admission was
< 100 mm.
• During period B, MUAC and WHZ at discharge were respectively > 125 mm and > -2 z scores
whatever MUAC categories at admission (Figure 2-3).

Objective
• To compare program outcomes and nutritional recovery as assessed by both
discharge criteria, 15% weight gain and MUAC 124 mm

Methods
• Routinely collected data of children admitted in a TFP in Burkina Faso between
2007 and 2011 were analysed
• Period A (September 2007 – March 2009)
- defined recovery at discharge by 15% weight gain, based on admission weight,
and absence of any pathology.
• Period B (April 2009 – December 2011)
- recovery at discharge was achieved at MUAC 124 mm,
with a 4 week minimum stay and absence of any pathology.
• Total period (September 2007 – December 2011) children were classified as:
- defaulters if they missed weekly appointments for 3 consecutive weeks in
ambulatory therapeutic center (A-TFC) or were absent 3 consecutive days in
intensive therapeutic center (I-TFC).
- non-responders if they failed to achieve discharge criteria after 6 weeks in ATFC without any associated pathology or chronic disease.

Conclusions
• The MSF TFP in Burkina Faso is an innovative community-based nutritional program using
MUAC as admission and discharge criterion since April 2009.
• 15% weight gain as a discharge criterion led to the paradox of more malnourished children
receiving shorter treatment and being discharged while still fulfilling admission criteria
• The change in discharge criterion resulted in redirection of resources to the most malnourished
while improving overall program coherency and efficiency.
• MUAC >124 mm as TFP discharge criteria is superior to 15% weight gain when admission is
based on MUAC. Percent weight gain as a discharge criterion should be abandoned.

• Rapid Diagnostic Tests (RDTs) are more and more popular due to their ease of use
and good performance for biological confirmation of malaria.
• The WHO Product Testing Programme, that evaluates malaria RDTs on a panel of
pre-characterised specimens, is an extremely valuable tool to compare RDTs currently
in the market.
• However, field performance of RDTs may di↵er significantly from the WHO in vitro
evaluation.

• To evaluate RDTs in two settings characterised by high and low malaria transmission:
To estimate performance in field conditions
To estimate the median time required to become negative after treatment
• To answer the questions:
Do RDTs perform di↵erently in high and low transmission settings?
How many days after an e↵ective treatment can a RDT positive result reliably be
considered a new malaria infection?

• Recruitment and follow-up for time to become negative
In each study site, 212 children positive for both RDTs and microscopy were
followed-up for 6 weeks
Three-days antimalarial treatment intake was supervised
RDTs and microscopy were repeated at fixed visit schedule: days 2, 3, 5, 7, 14, 21,
28, 35 and 42
Exclusion of patients with incomplete antimalarial intake or recurrent parasitaemia.

• Analysis for performance
Sensitivity, specificity, likelihood ratios, positive and negative predictive values
• Analysis for time to become negative
Time to become negative = the first day when RDT was reported negative during
follow-up
Estimates were computed as the probability for the test to become negative using
Kaplan-Meier survival function.

Summary and Discussion
• The median time to become negative was very long (42 days or more) for the HRP2
tests and very short (2 days) for the pLDH test.
• The two HPR2 tests were highly sensitive, but there was a remarkable di↵erence in
specificity between high and low transmission settings.
• The specificity of the pLDH test was higher, but sensitivity was lower than HRP2
tests in both settings, raising concern on the risk of missing some malaria cases.
• In the high transmission setting, the long time required to become negative of HPR2
tests and the high frequency of malaria infections may lead children to be positive to

the HPR2 tests for a large proportion of the malaria season. Nevertheless, we cannot
exclude that part of the false positive results could be explained by a sub-microscopic
parasitaemia.
• We still do not have a test that is highly sensitive and highly specific in all
epidemiological conditions. A choice is to be made between using an HPR2 test with
the consequence of over-treating patients and the risk of overlooking other possible
reasons for fever, and using a pLDH test with risk of missing malaria cases.

Conclusions
• TST was not a barrier to implement 36m IPT in an urban resource constraint
setting
• TST avoided unnecessary exposure to IPT for a high proportion of patients
• TST allowed initiation of long term IPT to the eligible patients
• Recommendations:
– Implement TST based IPT in urban settings
– Evaluate feasibility in rural settings

Gedaref state is the main endemic foci of visceral
leishmaniasis (VL), or kala azar, in Sudan. Yearly incidence
varies between 6.6 and 8.4 cases per 1000 persons, with a
large variation between villages. Since the end of 2009,
MSF OCG supports the Tabarak Allah (TBK) hospital for the
diagnosis and treatment of VL.
In this area, VL is believed to be mainly anthroponotic. It is
caused by Leishmania donovani, transmitted through the
sandfly Phlebotomus orientalis. The P. orientalis sandfly
populations peak at the late dry season and are
concentrated in areas with high densitiy of Acacia Seyal
and Balanites aegyptica trees that grow on black cotton
soil. The proportion of post kala azar dermal leishmaniasis
(PKDL) is affecting up to 50% of treated VL patients in
Sudan and it is suspected to play a role in the transmission.

Gender, in <10 years
Male
Female
Gender, 10 years and above
Male
Female

There is currently insufficient knowledge on risk factors for VL in areas where P. orientalis is the main vector
to clearly orient a control strategy. Consequently, we aimed to identify individual and household level
determinants of primary VL in highly endemic villages of Tabarak Allah area.
In particular, we investigated the role of suspected risk factors which could guide future control activities
such as contact with the environment (vegetation, domestic animals, characteristics of the house, yard and
surroundings), individual behaviours (travel, occupation, sleeping habits, evening activities, use of
mosquito nets, insect repellents, spraying activities) and the presence of patients with VL or PKDL among
relatives and neighbours.

METHODS
• Design: Unmatched case control study
• Target sample size: 270 cases / 810 controls
• Time: September 2012 to July 2013 (Dry season)
• Setting : 24 villages (46,564 population) with high VL incidence in TBK Hospital catchment area
• Participants:
Cases: successive patients treated in TBK Hospital for primary VL (probable: positive rk39 rapid test or
direct agglutination test; confirmed: positive lymph node aspirate and/or clinical response to VL treatment)
Controls : randomly selected in the villages using geographic spatial sampling; age, sex and village
distribution proportionate to the distribution in the target population; no VL symptoms (fever of any
duration and a history of recent weight loss or splenomegaly or lymphadenopathies); no previous VL
treatment; negative rk39 rapid test.
Both cases and controls: 6 months, resident in the same house in the study area for the past year.
• Data collection: Interview by questionnaire at home (for cases : during the month after discharge);
questions referred to the period preceding the onset of the case VL symptoms; where relevant, separate
questions were asked for behaviours in rainy and dry season.
• Statistics: Multivariate mixed logistic regression model (including village as a random effect).
Stepwise approach: (1) Variables associated with VL in univariate analysis (p<0.20) were adjusted for age,
sex and village; (2) Variables associated with VL (p<0.20) after adjustment were combined in multivariate
models by thematic sections and by season (exit criteria p>0.20); (3) Variables from these models were
combined in final multivariate logistic model (exit criteria p>0.05). Meaningful interactions tested (LR test).
“VL or PKDL among relatives and neighbours” kept in separately because likely on causal pathway.
• Ethical clearance: MSF ethical review board and Sudanese Research Ethics Review Committee.

*Adjusted for each others, age sex interaction and for village as a random effect (14% of variance, 95%CI 5 35%)

SEPARATE MULTIVARIATE MODEL
FOR VL AND PKDL
Age (median (IQR), per 10 years)
Female
Household member with VL in the
past year (per increase in 1)
Household member who developed
a PKDL like rash in the past year

Case
(N=198)
14 (7 32)
387 48.3

Control
(N=800)
9 (6 15)
74
37.4

Crude
OR
0.79
0.63

59

7.4

142

15

1.9

25

0.87
0.87

Adj*
OR
0.73
0.65

0.71
0.46

0.64
0.42

0.85
1.01

<0.001
0.053

71.7

19.1

13.0

28.3

21.4

13.5

33.9

<0.001

12.7

7.61

3.93

14.73

0.38

0.15

0.94

0.036

95%CI

95%CI

p value

*Adjusted for each other and for village as a random effect

LIMITATIONS
• Selection bias: patients with VL who did not present to TBK hospital, nomads or seasonal workers, and
patients who died from VL at home were not included. Some eligible controls were absent at time of
interview and not included. Also, some subclinical VL infections (rK39 negative) have probably been
included as controls. However, these likely represent only a minor proportion of cases and controls.
• Recall bias: patients with VL might have overestimated exposure to known determinants.
• Reverse cause: patients with VL might have changed their behaviour because of the disease.
• Observer bias: surveyors were not blinded of the participant VL status and this might have influenced
their interpretation of the participant answers. This was limited by standardization of all procedures.
• The multiple variables investigated might have lead to chance findings.

DISCUSSION AND CONCLUSION

Case (N=198)

n

Male

Case
(N=198)

Median (IQR)

OBJECTIVES

DEMOGRAPHIC CHARACTERISTICS

Control
(N=800)

<0.001

• Having a VL patient in the household in the past year was the strongest risk factor. Evening activities in
the rainy season were also associated with VL, as were the location of sleep, the presence of Acacia
nilotica in the surroundings of the yard, the distance to the nearest house yard and the use of ground
nut oil as animal repellent. Keeping animals in the yard at night appeared protective (except for dogs).
By contrast with previous studies, ethnicity, black cotton soil, Balanites aegyptica, Acacia seyal,
Azadirachta indica, use of mosquito nets, housing factors did not appear independent VL determinants.
• Although our results do not provide evidence of causality, they provide useful suggestions for the
development of relevant VL preventive measures as well as for guiding further studies.

RECOMMENDATIONS
• Target control efforts in and around households of patients diagnosed with VL
• Promote early diagnosis and treatment through health education campaigns
• Evaluate innovative targeted personal protection strategies: provide chemical repellent or insecticide
impregnated clothing for household members of all VL cases and to all inhabitants of villages
experiencing an increase in VL cases; develop health education campaign to promote their use
• Discourage the use of ground nut oil as animal repellent
• Because of the conflicting evidence on trees, systematic tree cutting should not be promoted
• Avoid keeping dogs around the house
• Additional research:
Assess innovative targeted personal protection strategies on sandfly population and infection
by L. donovani through an entomological assessment or randomised trial
Entomological study done in house yards, including blood meal analysis
Model of VL transmission across villages over time
Role of possible zoonotic transmission (especially with dogs)

INTRODUCTION
 The African meningitis belt has been affected for many decades by large epidemics of
meningitis mostly due to Neisseria meningitidis serogroup A (NmA).
 Other serogroups of N. meningitidis and other bacteria, such as Streptococcus pneumoniae
and Haemophilus influenzae type b (Hib), also cause meningitis.
 An effective and long-lasting conjugate vaccine against NmA, MenAfriVac, is being
introduced in the countries of the meningitis belt.
 Introduction of MenAfriVac in some regions of Chad in 2011 drastically reduced the
incidence of meningitis during the 2012 epidemic season, compared to non-vaccinated
areas (Figure 1).
 Moissala district in Southern Chad was not vaccinated in 2011 and had a meningitis
outbreak in 2012. The district was vaccinated with MenAfriVac in response to the
outbreak.
 We report results from a case-based meningitis surveillance system during and after the
2012 outbreak, continuing through end 2013 in order to show the evolution of cases
characteristic and germs identified after the introduction of MenAfriVac.

Table 1. Characteristics of suspect, probable and confirmed cases of meningitis in the

<0.001

5
MenAfriVac

4
3
1
0
2009

2010

2011

2012

Figure 1. Incidence of reported cases of meningitis cases in Chad, 2009-2012, in areas
vaccinated (red) or non-vaccinated (blue) with MenAfriVac in 2011
From Daugla et al., Effect of a serogroup A meningococcal conjugate vaccine (PsA-TT) on serogroup A
meningococcal meningitis and carriage in Chad: a community study. Lancet 2014;383:40-47.

METHODS
Surveillance procedures
 2012: Retrospective and prospective collection of demographic, clinical and biological data
for all suspect cases of meningitis from clinical registers and files
 2013: Case-based surveillance based on Chad national guidelines using case notification
files

Age group distribution

2

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

≥45 years
30-44 years
15-29 years
5-14 years
1-4 years
<1 year

All cases
(N=329)

Confirmed
cases (N=95)

Epidemic Period

All cases
(N=102)

Confirmed
cases (N=43)

Non-epidemic period

Figure 3. Age groups of all or confirmed meningitis cases in epidemic and post-epidemic

Laboratory analyses

periods, Moissala district, Chad, 2012-2013

 Cerebrospinal fluid (CSF) collected at district hospital in Moissala
 Pastorex Meningitis assay performed at district laboratory in Moissala
 Transisolate transport media inoculated and sent to General National Reference Hospital
laboratory in N’Djamena and Supranational Reference Laboratory in Oslo, Norway for
culture and PCR

Table 2. Distribution of organisms identified in the epidemic and post-epidemic periods,

Referrals
 During the 2012 epidemic, some cases were only seen in peripheral health centers. Since
the end of the 2012 epidemic, all suspect cases have been referred systematically from
health centers to the district hospital in Moissala.

Definitions
 Suspect case: fever with bulging fontanel or petechiae (or altered consciousness or other
signs of meningeal involvement in 2013) in children <1 year and sudden onset of fever with
neck stiffness or petechiae (or altered consciousness or other signs of meningeal
involvement in 2013) in adults
 Probable case: during the epidemic season, any suspect case. Outside of the epidemic
season, suspect case with turbid or purulent CSF, or with Gram suggestive of bacterial
meningitis, or with leucocyte count > 10 cells/mm3.
 Confirmed case: any suspect case with identification of a bacterial pathogen from the CSF
by latex test, culture or PCR.
 Epidemic period: weeks 1 to 19, 2012

SUMMARY
 As described in the rest of Chad, the incidence of meningitis fell considerably after
vaccination with MenAfriVac.
 While NmA was the main causative agent during the epidemic period, S. pneumoniae
was the most frequent causative organism in the post-epidemic period.

RESULTS

 The 2 cases of NmA in the post-epidemic period were not confirmed by culture or PCR,
and neither reported prior vaccination with MenAfriVac

60

Vaccination
50

 Sporadic cases of NmW135 were reported during the epidemic and post-epidemic
periods.

 Outside the epidemic setting, meningitis cases, mostly due to S. pneumoniae, carry a high
burden (number of cases, high case fatality). Vaccination against S. pneumoniae is
necessary to continue the fight against meningitis.
 Case-based surveillance was feasible to implement in this setting, and is needed to
continue following the epidemiology of meningitis after the introduction of MenAfriVac.

Efforts to describe the epidemiology of infected war-related injuries are complicated
by difficult access to patients, limited availability of high-quality laboratory support and
the widespread empirical use of antibiotics. A surgical project of MSF in Amman,
Jordan, provided an opportunity to describe the microbiology of war injury in Syrian
civilian patients who were able to seek care in Amman.

This study demonstrates that in our cohort an important proportion of MDR organisms
are found amongst war-injured patients from Syria. For a surgical project, MDR
organisms lead to formidable diagnostic, treatment and infection control challenges.
These include the need for ongoing access to high quality clinical microbiology for
individual patient care, the need for late-generation antibiotics typically given
parenterally for up to 6 weeks, the need for trained infection prevention personnel and
the need for sufficient hospital space to allow for single-room or cohort isolation of
patients highly-resistant strains.

We reviewed surgical biopsy results obtained from Syrian war-injured civilians
between August 2011 and March 2013. Data were collected from programmatic
databases and from individual chart reviews in Amman.
Organism

RESULTS
Between August 2011 and March 2013, 1586 Syrian patients were evaluated in the
project representing 35% of total arrivals in both the inpatient and outpatient
departments. Among 204 Syrian patients admitted to the surgical inpatient ward, 61
(18%) had a suspected infection at initial evaluation (98% male; median age 26);
Among these 61 patients with a pathogen isolated, evacuation to Amman often
involved significant delay; the median time from injury to culture was 5 months [IQR
1.2-8.1]. Injuries that resulted from gunshot wounds (52%) and bombs (33%)
represented the main etiologies of trauma. Forty-five (74%) of them were found to
have a sample positive for one or more bacterial isolates. Among Syrian surgical
patients presenting with delayed definitive management of infected orthopedic and
soft tissue war injuries, multidrug-resistant (MDR) organisms notably MDR gramnegative pathogens and methicillin-resistant Staphylococcus aureus were frequently
recovered from deep surgical samples.
PER PATIENT
Injury Location
Upper extremity
(N = 14 patients)

CONTEXT
Malaria is endemic in the Democratic Republic
of Congo (DRC), where 97% of the population
lives in a high transmission zone. With more
than 9 million cases reported in 2011, malaria
remains the leading cause of morbidity in the
DRC.
During the first half of 2012, the number of
malaria-related cases and deaths in Orientale
Province was higher than in previous years.
In the face of this resurgence, Médecins Sans
Frontières (MSF) implemented an emergency
malaria management programme in some of
the hardest-hit health areas (HA) in Orientale
province’s Ganga and Pawa health zones.
Together with these interventions, a crosssectional retrospective household survey was
conducted in order to describe malaria-related
mortality and the malaria prevalence in the
Danga HA.

RESULTS (continued)
2. Rapid diagnostic test (RDT)
The RDT was performed on 4,448 people
The RDT was positive in 2,111 people (positivity rate = 47.5%)
Table 1: Distribution of positive RDTs by age in Danga and Nemanzi localities

Age group
0-4 years (n=821)
5-9 years (n=670)
10-14 years (n=475)
>14 years (2482)

Thick and thin films were done on a sample of 579 people.
The thick film was positive in 104 people (17.9%)
Table 2: Results for thick and thin films

OBJECTIVES

Frequency

1. Primary objective:
- To estimate the retrospective malaria-related mortality and the malaria prevalence in the Danga HA.

0
1 - 999
1000 - 9999

2. Secondary objectives:
- To assess the retrospective mortality from 1 January 2012 to
25 September 2012 among Danga HA residents
- To assess the malaria prevalence in the health area
- To assess the population’s haemoglobin level in the Danga HA
- To assess the insecticide-treated mosquito net coverage in the Danga HA.

METHODS
1. Study location
The Danga health area, located in the Ganga health zone, is divided into two localities (Danga and Nemanzi)

(%)
(81.8%)
(12.0%)
(5.0%)
(1.2%)

98 (16.9%)
4
(0.7%)
4
(0.7%)
6

(1.0%)

4
1
10

(0.7%)
(0.1%)
(1.7%)

*: Mixed infections found in two people
Table 3: Breakdown of RDT and thick film results by age group
RDT

AS
DANGA

0-4 years (n=107)
5-9 years (n=86)
10-14 years (n=62)
>14 years (n=324)
Figure 2: The Danga health area

Positive (%)
42 (39.3%)
47 (54.7%)
43 (69.4%)
147 (45.1%)

Thick film
Negative (%)
65 (60.7%)
39 (45.3%)
19 (30.6%)
177 (54.9%)

Positive (%)
17 (15.9%)
20 (23.1%)
19 (30.6%)
48 (14.8%)

4. Haemoglobin

2. Study type
An exhaustive cross-sectional retrospective mortality and prevalence survey was conducted from 5 September to
25 September 2012 among 4,958 people (51.5% female) in 874 households in the Danga HA

The protocol was submitted to the DRC Ministry of Health Ethics Committee and the MSF Ethics Committee.
Written informed consent was obtained from each head of household. Everyone with a positive RDT was treated
for malaria according to the national protocol (artesunate + amodiaquine)

Retrospective mortality
Malaria-related mortality was high
High prevalence of malaria
The RDT and thick film were positive in 47.5% and 17.9%, respectively, of people surveyed. Plasmodium
falciparum was the species found most frequently (94.2%). Treatment was administered to everyone with a
positive RDT.
Low prevalence of anaemia
Anaemia was observed in 2.8% of people surveyed. Only 3.7% of children under 5 years were anaemic.
Roughly half mosquito net coverage
56.2% of households had at least one mosquito net. Of the 780 mosquito nets reported, only 56.8% were
attached.

4

CONCLUSION
The high malaria-related mortality combined with high malaria prevalence and only about 50% mosquito net
coverage suggest a worrisome malaria situation in the Danga HA; this should prompt a stepping-up of malaria